Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency: When is it indicated, what is the goal and how to do it?

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ABSTRACT

Pancreatic exocrine insufficiency with steatorrhea is a major consequence of pancreatic diseases (e.g. chronic pancreatitis, cystic fibrosis, severe acute necrotizing pancreatitis, pancreatic cancer), extrapancreatic diseases like celiac disease and Crohn's disease, and gastrointestinal and pancreatic surgical resections. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality. Therapy of pancreatic exocrine insufficiency is based on the oral administration of pancreatic enzymes aiming at providing the duodenal lumen with sufficient amount of active lipase at the time of gastric emptying of nutrients. Administration of enzymes in form of enteric-coated minimicrospheres avoids acid-mediated lipase inactivation and ensures gastric emptying of enzymes in parallel with nutrients. Despite that, factors like an acidic intestinal pH and bacterial overgrowth may prevent normalization of fat digestion even in compliant patients. The present article critically reviews current therapeutic approaches to pancreatic exocrine insufficiency.

Section snippets

INTRODUCTION

Pancreatic exocrine insufficiency is a major consequence of diseases leading to a loss of pancreatic parenchyma (e.g. chronic pancreatitis, cystic fibrosis), obstruction of the main pancreatic duct (e.g. pancreatic and ampullary tumors), decreased pancreatic stimulation (e.g. celiac disease), or acid-mediated inactivation of pancreatic enzymes (e.g. Zollinger-Ellison syndrome). In addition, gastrointestinal and pancreatic surgical resections (e.g. gastrectomy or duodenopancreatectomy) are

REVIEW

The aim of pancreatic enzyme substitution therapy is not only to avoid maldigestion-related symptoms, but mainly to ensure a normal nutritional status. Therapy of pancreatic exocrine insufficiency is based on the oral administration of exogenous pancreatic enzymes. Together with that, dietary modifications have classically played an important role that nowadays should probably be reconsidered.

CONCLUSIONS

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    Pancreatic exocrine insufficiency is a frequent and life-threatening condition associated to different pancreatic and extrapancreatic diseases (acute pancreatitis, chronic pancreatitis, cystic fibrosis, pancreatic cancer, GI and pancreatic sugery).

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    Therapy of pancreatic exocrine insuficiency should avoid symptoms and ensure a normal nutritional status.

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    Oral pancreatic enzymes in form of enteric-coated mini-microspheres are the therapy of choice. A minimum dose of 40-50,000 Ph.U/lipase is usually

REFERENCES (25)

  • JE Domínguez-Muñoz

    Pancreatic enzyme therapy for pancreatic exocrine insufficiency

    Curr Gastroenterol Rep.

    (2007 Apr)
  • JE Domínguez-Muñoz et al.

    Oral pancreatic enzyme substitution therapy in chronic pancreatitis: is clinical response an appropriate marker for evaluation of therapeutic efficacy?

    JOP.

    (2010 Mar 5)
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